Good Faith Estimate for Health Care Items & Services Good Faith Estimate for Health Care Items & Services to Business Office Patient InformationPatient Name:(Required) First Middle Last Address:(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email: Phone:(Required)Contact Preference(Required) By mail By email By phone Date of Birth:(Required) MM slash DD slash YYYY Insurance InformationInsurance Company(Required)If applicable, enter 'no insurance'Insurance Group #Insurance Member #Patient DiagnosisPrimary Service or Item Requested/Scheduled(Required)Physician/Provider for Procedure/ServiceDate of Procedure/Service(Required) Is Scheduled Is Not Scheduled Scheduled Date of Procedure/Service MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Δ